macular function surveillance revisited
DESCRIPTION
Presentation on the use of newer technologies to assist patients with macular degeneration with monitoring their vision at homeTRANSCRIPT
Macular Function Macular Function Surveillance RevisitedSurveillance Revisited
Rick Trevino, ODRick Trevino, OD
VA Outpatient ClinicVA Outpatient Clinic
Evansville, INEvansville, IN
Fine SL, et al. Ophthalmology. 1985;92:603-609.Fine SL, et al. Ophthalmology. 1985;92:603-609.
Macular Function SurveillanceMacular Function Surveillance
Earlier intervention Earlier intervention improves outcomeimproves outcome– Argon LaserArgon Laser– Photodynamic TherapyPhotodynamic Therapy– Anti-VEGFAnti-VEGF
Home surveillance of Home surveillance of macular function can macular function can result in earlier result in earlier detection of the detection of the symptoms of CNVsymptoms of CNV
More effective in More effective in younger patientsyounger patients
Marmor MF. Surv Ophthalmol. 2000;44:343-353.Marmor MF. Surv Ophthalmol. 2000;44:343-353.
Macular Function SurveillanceMacular Function Surveillance
Richard Förster (1862)Richard Förster (1862)
Marc Amsler (1953)Marc Amsler (1953)
Ted Schlaegel (1968)Ted Schlaegel (1968)
MPS (1983)MPS (1983)
Entoptic Perimetry (2000) Entoptic Perimetry (2000)
Hyperacuity Perimetry Hyperacuity Perimetry (2003)(2003)
Computerized Amsler Computerized Amsler Grid (2004)Grid (2004)
Schuchard RA. Arch Ophthalmol. 1993;111:776-780.Schuchard RA. Arch Ophthalmol. 1993;111:776-780.
Disadvantages of Amsler GridDisadvantages of Amsler Grid
Low SensitivityLow Sensitivity– 50% of scotomas missed50% of scotomas missed
– Only 30% of pts on Amsler Only 30% of pts on Amsler surveillance that develop CNV surveillance that develop CNV detected their lesion using the detected their lesion using the grid grid (Zaidi, et al. Eye. 2004;18:503.)(Zaidi, et al. Eye. 2004;18:503.)
Completion PhenomenaCompletion Phenomena– Perceptual filling-in of defectsPerceptual filling-in of defects
Eccentric FixationEccentric Fixation
Poor Compliance (50%)Poor Compliance (50%)
Nazemi PP, Fink W, Lim JI, Sadun AA. Retina. 2005;25:446-453.Nazemi PP, Fink W, Lim JI, Sadun AA. Retina. 2005;25:446-453.
Improving the Amsler GridImproving the Amsler Grid
Red GridRed Grid
Threshold GridThreshold Grid
– Cross-Polarizing Cross-Polarizing LensesLenses
– Low Contrast CardsLow Contrast Cards
– Computerized Computerized Amsler gridAmsler grid
Non-Grid Surveillance TechniquesNon-Grid Surveillance Techniques
Environmental Environmental AmslerAmsler
Entoptic PerimetryEntoptic Perimetry
Hyperacuity Hyperacuity PerimetryPerimetry
Internet-based Internet-based ProgramsPrograms
Fine AM, et al. Arch Ophthalmol. 1986;104:513-514.Fine AM, et al. Arch Ophthalmol. 1986;104:513-514.
Environmental AmslerEnvironmental Amsler
Monocular inspection of Monocular inspection of straight lines in your straight lines in your surroundings for signs of surroundings for signs of distortiondistortion– Door framesDoor frames– Telephone polesTelephone poles– Ceiling or floor tilesCeiling or floor tiles– Crossword puzzlesCrossword puzzles– Lines of textLines of text
Encourage pts to develop Encourage pts to develop the habit of monocularly the habit of monocularly assessing their visionassessing their vision
Brown JC, Kylstra JA, Mah ML. Ophthalmology. 2000;107:755-759.Brown JC, Kylstra JA, Mah ML. Ophthalmology. 2000;107:755-759.
Entoptic PerimetryEntoptic Perimetry
Random flickering of black Random flickering of black and white dots on video and white dots on video display (TV “snow”)display (TV “snow”)
Makes scotomas visible to Makes scotomas visible to the patient so they can be the patient so they can be monitored for changemonitored for change
89% more sensitive than 89% more sensitive than Amsler grid in detecting Amsler grid in detecting diabetic macular edemadiabetic macular edema
Home surveillance with Home surveillance with TV or computerTV or computer
Adachi M, Shirato S. Jpn J Ophthalmol. 1994;38:392-399.Adachi M, Shirato S. Jpn J Ophthalmol. 1994;38:392-399.
Entoptic PerimetryEntoptic Perimetry
Advantages – Simultaneous examination of the whole visual field – Subjective experience of visual field defects– Can be performed at home using a conventional TV Can be performed at home using a conventional TV
DisadvantagesDisadvantages– Low sensitivity for congenital or Low sensitivity for congenital or suprageniculate
lesions (blind spot, most hemianopic defects)lesions (blind spot, most hemianopic defects)– Qualitative examinationQualitative examination
Kampmeier J, et al. Klin Monatsbl Augenheilkd. 2006;223:752-756.Kampmeier J, et al. Klin Monatsbl Augenheilkd. 2006;223:752-756.
Hyperacuity PerimetryHyperacuity Perimetry
Utilizes Vernier acuityUtilizes Vernier acuityMore sensitive than Amsler grid More sensitive than Amsler grid in detecting late-stage vision in detecting late-stage vision defects in AMDdefects in AMD– Early AMD (PHP: 30%, AG: 30%) Early AMD (PHP: 30%, AG: 30%) – Interm AMD (PHP: 46%, AG: 52%)Interm AMD (PHP: 46%, AG: 52%)– GA (PHP: 87%, AG: 67 %)GA (PHP: 87%, AG: 67 %)– Wet AMD (PHP: 84%, AG: 80 %)Wet AMD (PHP: 84%, AG: 80 %)
Potentially able to differentiate Potentially able to differentiate pts with CNVpts with CNVHome surveillance?Home surveillance?
http://www.meditec.zeiss.comhttp://www.meditec.zeiss.com
Hyperacuity PerimetryHyperacuity Perimetry
PreView preferential PreView preferential hyperacuity perimeter hyperacuity perimeter – Macular perimetry using a dot Macular perimetry using a dot
deviation signal deviation signal – Tests central 14Tests central 14˚ with 500 ˚ with 500
data points in 5 mindata points in 5 min– Preferential looking analysis:Preferential looking analysis:
Quantitatively maps field Quantitatively maps field defects using artificial defects using artificial distortions of the deviation distortions of the deviation signal signal
– Algorithm analysis of the data Algorithm analysis of the data is designed to detect the is designed to detect the presence of CNVpresence of CNV
Hyperacuity PerimetryHyperacuity Perimetry
AdvantagesAdvantages– Quantitative Quantitative – Positive predictive Positive predictive
valuevalue
DisadvantagesDisadvantages– Requires expensive Requires expensive
specialized specialized equipmentequipment
– Not suitable for Not suitable for home monitoringhome monitoring
Internet-Based ProgramsInternet-Based Programs
Currently available: Currently available: Downloadable AmslerDownloadable Amsler
Great potential for Great potential for newer generation newer generation teststests– Entoptic perimetryEntoptic perimetry– Hyperacuity perimetryHyperacuity perimetry– Threshold AmslerThreshold Amsler
Internet-Based ProgramInternet-Based Program
Free web-based Free web-based entoptic perimetry entoptic perimetry computer programcomputer programRecord scotomas Record scotomas and alert patient to and alert patient to significant changessignificant changesResearch study to Research study to compare defects on compare defects on Amsler grid and Amsler grid and entoptic perimetry in entoptic perimetry in pts with AMDpts with AMD
Home SurveillanceHome Surveillance
Amsler GridAmsler Grid– Reinforce compliance Reinforce compliance
Environmental AmslerEnvironmental Amsler– Make it a habit to check Make it a habit to check
monocular visionmonocular vision
Television Entoptic Television Entoptic PerimetryPerimetry– More sensitive than More sensitive than
AmslerAmsler
Thank You!Thank You!